EMPLOYMENT APPLICATION. LAST NAME FIRST INITIAL Position applying for: Mailing Address: SIRH IS A TOBACCO FREE CAMPUS AND A DRUG FREE WORKPLACE

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1 SIRH IS A TOBACCO FREE CAMPUS AND A DRUG FREE WORKPLACE Mailing : 3104 Blackiston Boulevard New Albany, IN (812) EMPLOYMENT APPLICATION It is the policy of SIRH to afford equal opportunity to all employees and applicants. We comply with all Federal, State and Local regulations as they pertain to Equal Employment Opportunity. The use of this form does not mean there are positions open and does not obligate SIRH in any way. Your employment application will be retained for 6 months. You must reapply if you wish to be considered for employment beyond this period of time. Date Available: Shift position preferred: Day Evening Night Type of position preferred: Full time Part time PRN LAST NAME FIRST INITIAL Position applying for:

2 PERSONAL DATA: Name: (Last) (First) (Middle) (Maiden) Social Security No. Present : (Street) (City, State, Zip) Home Phone No. Work/Cell/Pager No. ( ) ( ) Have you ever been Have you ever been convicted of a crime, including Date & Nature of convicted of a felony? misdemeanors and traffic offenses? conviction(s): Yes No Yes No If yes, explain: Have you ever been convicted of a criminal offense related to health care or have you ever been debarred, excluded or otherwise ineligible for participation in a federal health care program such as Medicare or Medicaid? Yes No Have you ever been the subject of an investigation by any private, federal or state health insurance program? Yes No If yes, please provide explanation and dates In the last 10 years, were you fired from any job, did you quit after being told that you would be fired, or did you leave by mutual agreement because of specific problems? Yes No If yes, please explain Are you 18 years of age or older? Yes No Are you currently employed? Yes No Expected Rate of Pay If so, may we contact your present employer? Yes No Phone # $ per Have you ever been employed by List all Relatives (and their departments) who work at this facility: SIRH? Yes No If yes, give dates and department: How were you referred to our facility? Professional Journal Job Fair Newspaper Ad SIRH Employee - Name of SIRH Employee EDUCATION School Circle Last School Name/Location Degree Degree Major or Year Completed Received Course of Study High School GED Y N College Y N Graduate Business College or Vocational School Y N Y N PROFESSIONAL REGISTRATION AND/OR LICENSURE Do you possess any kind of professional license, certificate, or registration (excluding driver s license?) Yes No If yes, please fill out the following information: Type State Original Issue Date License No. Expiration Date Verified By If not licensed in Indiana, have you applied for an Indiana license? Yes No. Has your license in any state ever been denied, limited, suspended, sanctioned, revoked, voluntarily or involuntarily relinquished, or not renewed? Yes No. If yes, please provide explanation and dates Are there any actions that have been initiated or are pending against you by any state licensing board? Pending Settled Resolved VOLUFORMS /08

3 EMPLOYMENT HISTORY START WITH YOUR PRESENT OR MOST RECENT EMPLOYER and follow with former places of employment including military experience, temporary, and all other employment. EVEN IF A RESUME IS ATTACHED, PLEASE COMPLETE ALL INFORMATION. Name: Phone No. Phone No. Phone No. Phone No. Phone No. FOR REFERENCE AND VERIFICATION PURPOSES, HAVE YOU EVER WORKED UNDER ANOTHER NAME? IF SO, INDICATE NAME AND COMPANY. Company: Name: Company: Explain any periods of unemployment: PROFESSIONAL REFERENCES (OTHER THAN RELATIVES) Name/Business and Professional Relationship Phone Number Home Business Home Business If not a citizen of the United States, do you have the right to remain and work in the United States? Yes No. If yes, explain: Alien Registration Number (Visa #) Expiration Date Type of Card

4 May we contact the employers you listed? Yes No If no, explain: What was the former position held which you most enjoyed? Briefly describe reasons. What was the former position held which you least enjoyed? Briefly describe reasons. APPLICANT CERTIFICATION AND AGREEMENT - READ CAREFULLY In applying for employment I want Southern Indiana Rehab Hospital (SIRH) to be fully informed of my previous record, and I hereby authorize SIRH to investigate my background and to obtain any and all information which may concern me. I hereby release all persons, schools, corporations, military and government agencies, credit bureaus and law enforcement agencies from any liability in furnishing such information. I understand that the SIRH policy requires me to submit a sample of my urine and blood for chemical analysis to determine the presence or absence of drugs and/or alcohol. I consent freely and voluntarily to provide such urine and/or blood specimens prior to the start of my employment and I understand that employment is contingent upon passage of this chemical analysis. I further agree to any future request for urine and/or blood specimens as outlined by the SIRH Alcohol and Drug Policy. I hereby release and hold harmless SIRH and its employees and agents from any liability whatsoever arising from any and all requests to furnish specimens or the testing process. I also authorize any laboratory testing my urine and/or blood requested by the SIRH Alcohol and Drug Policy to release the results to SIRH and I hereby release any such laboratory, its employees and agents and hold them harmless from any liability whatsoever arising from the release of such information to SIRH. prevent further consideration of my application prior to being hired. I further understand that any offer of employment shall be subject to a reference check. I understand and agree that, should I be offered employment, my start date may be conditioned on the results of a medical examination, the cost of which, if administered, will be paid by SIRH. I further agree to abide by the policies, procedures and practices of SIRH. I understand that conditions may require me to work shifts other than the one for which I am applying and I agree to such scheduling change as directed by my supervisor or administrator of this organization. This application is not an employment contract and cannot create an employment contract. I understand that my employment would be at will and could be terminated at any time by either SIRH or myself. RELEASE: I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my licensure status and my licensure history. I fully understand that any misrepresentation of facts on this application shall be sufficient cause for dismissal in the event I am hired, or shall be sufficient cause to Applicant Signature Date

5 The Road to Excellence ATTITUDE At SIRH we believe that we are here to serve our customers. APPEARANCE Our appearance represents the SIRH organization. Therefore, our grooming and dress will reflect our respect for our customers. CALL LIGHTS We will answer call lights in a way that demonstrates the care, courtesy and respect our customers deserve. COMMUNICATION The goal of communication is understanding. We must be committed to listening attentively to our customers in order to fully understand their needs. COMMITMENT TO CO-WORKERS As SIRH employees, we are linked to one another by a common purpose: serving our customers and our community. CUSTOMER WAITING We strive to provide our customers with prompt service, always keeping them informed of delays and making them comfortable while they wait. PRIVACY We will ensure our customers right to privacy and modesty by creating and maintaining a secure and trusting environment. PROFESSIONALISM Be courteous and respectful to customers and colleagues. Do your job and take personal ownership of it. SAFETY AWARENESS Safety will be the responsibility of all SIRH employees to ensure an accident-free environment. SENSE OF OWNERSHIP By this we mean taking pride in what we do and feeling responsible for the outcomes of our efforts. I have read the above performance standards and understand that these behaviors are an expectation of SIRH team members. Signature Date

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